Inspection·November 2, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #27's admission MDS assessment dated [DATE] revealed a BIMS score of 14 (intact cognition). The resident was coded as having delusions, wandered daily, one person staff assistance for ADL care, not steady walking, used a wheelchair and walker, and frequently incontinent of bladder/bowel. The resident was coded as having medically complex conditions, was a fall risk, and received oxygen therapy. Residents Affected - Some 3)Record review on 11/02/22 of Resident #45's Order Summary Report revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of generalized anxiety disorder, wandering, vitamin d deficiency, other malaise, and vascular Dementia. Record review on 11/02/22 of Resident #45's EMR Chart record revealed no initial baseline care plan. Record review of Resident #45's admission MDS assessment dated [DATE] revealed a BIMS score of 07 (Severely impaired). Resident #45 was coded as having other behavior directed towards others, one person staff assistance for ADL care, not steady but able to stabilize without staff assistance, occasionally incontinent to bladder and always continent to bowel. Her diagnoses listed were hypertension, hyperlipidemia, non-Alzheimer's dementia, and anxiety. 4) Record review on11/02/22 of Resident #49's Order Summary Report revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of anxiety disorder, acquired absence of bilateral breasts and nipples, major depression, recurrent, mild, Alzheimer's disease and encounter for immunizations. Record review of the Standard Assessments section of Resident #49's EMR Chart revealed on 07/12/22 an Interim Care plan was initiated, and the status was In Process status. Record review of Resident 49's admission MDS assessment dated [DATE] revealed a BIMS score of 04 (severely impaired). Resident #49 was coded as having behavior symptoms directed toward others, required setup and one person staff assistance for most ADL care, not steady with walking. She was frequently incontinent of bowel/bladder and had diagnoses of anxiety, and depression. Interview on 11/02/22 at 12:35 pm, MDS C stated she had been working at the facility since July 2022. She stated the facility had no issues with incomplete baseline care plans. She stated the DON opened the baseline care plan assessments for new admissions that were electronically created by the DON. MDS C stated she filled in whatever triggered for the resident automatically and reviewed to ensure all their information was included and, then the DON reviewed it and closed it out. She stated the baseline care plans were under the assessments tab and not in the miscellaneous section of the EMR charts and added there were no paper versions. She stated the baseline care plans were to be completed by the DON within 24 hours of the resident's admit date . She stated the importance of doing baseline care plans were to identify what the residents' problems, diagnoses, goals and what their interventions were to get better care and to be aware of what each patient needed to ensure a better quality of life. She stated Resident #45's baseline care plan was initiated by the former DON on 03/17/22 upon admission, and it was before she worked at this facility. She stated she did not see Resident #45's baseline care plan was completed in the EMR Chart. She said on 08/31/22, she and DON reviewed her care plans and was unaware Resident #45's baseline care plan was still open (incomplete). She stated Resident #27's baseline care plan was not in the EMR Chart record. She said on 09/19/22, the DON opened it and was not sure why it was not completed. She stated Resident #49's baseline care plan was opened on 07/12/22 by the DON but it was still In progress in Resident #49's EMR Chart record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and was not sure why. She stated not seeing Resident #19's baseline care plan was completed in the Assessment tab but saw that the former MDS Coordinator and DON revised it on 07/24/22. She stated they used an EMR clinical dashboard for alerts for overdue assessments but, she did not like to use it because it pulled up discharged residents. She stated the nurses, and the administrative nursing department was responsible for ensuring baseline care plans were completed. She stated she would look for the missing assessments and provide them if found. MDS C did not provide any further documentation to confirm the resident's baseline care plans had been completed. Interview on 11/02/22 at 1:36 pm, the DON stated she had been working at the facility since July 2022. She said the nursing staff had a new admission's process in place to ensure the baseline care plans were competed, that started a few weeks ago. She stated Resident #45 was admitted before she started working at this facility, Resident #27 was admitted [DATE], Resident #49 was admitted before 08/01/22 and Resident #19 was admitted [DATE]. She stated she did not see any of their baseline care plans in the EMR Chart records and would have to see if they were in the medical records room. She stated the RN's used an admission checklist to ensure the baseline care plans were done and whoever opened it also were to complete it within 24 hours. She stated MDS C did not do the baseline care plans and was not sure who opened these four residents base line care plans. She stated if the resident's baseline care plans were not completed, the staff would not know how to take care of the residents. She stated she was responsible for ensuring the baseline care plans were done and reviewed the initial audits report in the facility's EMR system with a scheduled status of which assessments were opened, in progress and completed. She stated a lot of times the nurses forgot to lock the baseline care plans to complete them. She stated her expectations for baseline care plans were for them to be done within 24 hours. She stated the assessments were normally done electronically and there were no paper files because all of the records were uploaded into the EMR system. She stated she would provide them to surveyor if she found them. The DON did not provide any documentation to confirm these baseline care plans had been completed. Interview on 11/02/22 at 6:31 pm, the Administrator stated they had a process in place to address initial baseline care plans and was unaware these four residents did not have theirs. She stated the expectations for baseline care plans were for them to be completed and established in the resident's records in a timely manner. Record review of the New admission Checklist undated revealed, Initial beside each completed item .This should be completed within 24 hours and placed under DON door .10. Baseline Care plan (this can only be opened and completed by RN, if you are unable to complete let DON know) Record review of the DON's Job description revised March 2022 revealed, The DON is to help oversee daily clinical operations of residents and staff. Job duties would include but not limited to staffing, clinical metrics, and coordination of care under the direct supervision of an Administrator Record review of the facility's Care Plans - Baseline Policy revised 03/2022 revealed, Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission .1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet the professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for one (Resident #29) of two residents reviewed for intravenous fluids. Residents Affected - Few The facility failed to change and maintain the integrity of the PICC line dressing per professional standards. This failure could affect residents by placing them at risk for infections and cross-contamination. Findings included: Review of Resident #29's Minimum Data Set assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses of sepsis (the body's extreme response to an infection), muscle wasting, kidney failure, and weakness and required intravenous(administered into a vein) antibiotic therapy for 13 days via her PICC line. Review of Resident # 29's Order Summary Report dated 09/29/22 revealed the physician had ordered for the PICC line dressing to be changed every 7 days, to be done every Saturday. Review of Resident #29's Informed Consent Special Procedure- PICC dated 10/12/22 revealed she had consented to the insertion procedure. Observation on 10/31/22 at 10:30 AM of Resident #29's PICC line revealed a dressing, dated 10/12/22. Interview on 10/31/22 at 11:00 AM with LVN A revealed after observation of Resident #1's rt arm that the PICC line dressing had a date of 10/12/22 and said that it was supposed to be changed every Saturday by the weekend shift nurse. She said that she did not realize it had not been done and said that it was her responsibility to assess the residents' intravenous sites each day before administering medications through the port, but she failed to do so in the morning. She reported that the protocol for changing this type of peripheral inserted line was that it should be changed every seven days or whenever it became soiled and to follow the physician orders. LVN A said she would get the dressing changed immediately. Interview and observation on 10/31/22 at 11:45 AM with ADON revealed, he read the date on Resident #29's PICC line dressing and confirmed the dressing was dated 10/12/22 and stated the dressing should have been changed every seven days on Saturday. After the ADON removed the old dressing, observation of the site revealed there was no redness or swelling noted to the resident's arm. Interview on 10/31/22 at 4:00 PM with the DON revealed, yes, the resident's PICC line dressing should have been changed. No, I don't know why it has not been changed. I do know that it should be changed every 7 days or when it is loose or soiled. She stated the administrative nursing team, the DON and ADON as well as nursing staff were collectively responsible for ensuring nurses assess the PICC line insertions sites daily to prevent infections and perform physician ordered dressing changes and input the resident dressing changes into resident electronic records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's current Central Venous Catheter Dressing Changes policy and procedure, dated December 2021, reflected the purpose of this procedure was to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressing. Change transparent semi-permeable membrane dressings at least every 5-7 days and as needed (when soiled, wet or not intact). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage and sanitation. 1. The facility failed to discard food stored in the refrigerator, freezer, and dry storage room that was expired or past the open date timeframe. 2. The facility failed to clean the kitchen and floors thoroughly and replace kitchen utensils and dish racks that were old, discolored and appeared unclean. These failures could place residents at risk for ingesting cross contaminated food, which could result in food-borne illnesses, health decline and serious illness. Findings Included: Observation on 10/31/22 at 10:15 am, of the kitchen revealed: -Two small white trash cans under the kitchen sink that had foot pedals with an accumulation of what appeared to be black dried mud. -Upright metal refrigerator contained- previously opened bag of diced chicken in a blue bag without an open date and use by date. 1 Gallon of [NAME] Slaw opened 8/24/22 without an expiration date on the container, 1-gallon Italian dressing opened 8/12/22 without an expiration date on the container and 1 gallon Mayonnaise previously opened 10/11/22 without an expiration date on the container. Two five-pound containers of cottage cheese open date 10/15/22 without an expiration date on the container. -White refrigerator contained- brownish dried splash stains outside and inside of the refrigerator. -Dry storage room contained - A three shelf metal cart that had a dried white liquid substance spilled on the top and 2nd shelf next to the dried can goods. Bread was previously opened and no open date label. 1 gallon Teriyaki sauce previously opened 8/30/22 without an expiration date, bag of vanilla wafers previously opened dated 10/18/22. On a side rack near the dry storage entrance, a small box of baking soda appeared old and previously opened was not sealed and cupcake baking cups were previously opened were not closed or sealed and exposed to the air. The side rack had several layers of brownish dust and debris on it. - Upright metal freezer contained - bag of yellow squash, sugar cookies, dinner rolls and breaded chicken strips that were previously open without open label dates and the expiration dates were unknown. -Dishwasher area contained - three white sharp knives appeared worn with a beige and brownish color, four dish racks appeared very dirty with a smeared/stained blackish color. And the brown dishwasher rack dolly had very rusty wheels, and a lot of blackish smudged dirt, crumbs and debris particles (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on it. And under the dishwasher sink, there was a brown dishpan that appeared to have a darker brown color with dried water (or soap) discoloration and small debris particles, at the bottom of it. -The kitchen flooring in the dried storage area corners had built up blackish dirt and small particle debris in the corner between the freezer and storage rack and the corner in the dishwashing area and flooring between the stove and prep table had debris and built-up dirt and sand. The baseboards were missing, in the dishwashing room and the wall had areas of white and brownish discolorations to it. -The air conditioner unit's vent had dried brownish stains on it. -A worn, greyish and stringy dish towel was laying by the three-compartment sink. -Underneath the fire extinguisher, the wall had a huge brownish and greyish stain that was square in shape. -Underneath one of the prep tables, there was a white shelf liner underneath the baking pans with brownish splash stains on them. -Outside the kitchen door there was a three-shelf black cart that appeared very dirty with white stains, brownish powder, small particles of trash with an empty resident pitcher and two empty serving pitchers. -The kitchen door to the dishwasher room had a metal guard protector was very dirty with black and brownish stains on it. Interview on 10/31/22 at 10:45 am, the Dietary Director stated all dietary staff were responsible for ensuring the food and drinks were labeled properly and expiration dates checked. She said last Friday 10/28/22, she was not at work when they received a food delivery and was not sure why there were no dates on some of the food. She stated with being so busy and only having two staff during the day to cook, serve and put food up was a problem and stated she needed a third person and one weekend person to work. She stated she just started working this position and getting systems in place. She stated the dietary staff were supposed to make sure the serving carts were clean before going back into the dry storage room and was not sure what was on the metal cart in the dry storage room. She stated [NAME] E worked 1:30 pm to 8:00 pm and was in charge of cleaning and added the yellow squash had been in the freezer since last Monday 10/24/22 and was not sure why there was no open date and expiration date on it. She stated the undated bag of dinner rolls were delivered to this facility, last Friday 10/28/22 and added she was not sure why the bag of sugar cookies did not have an open date label and expiration date. She stated the sugar cookies were used last night 10/30/22 because her [NAME] called her last night asking whether or not to use them because they looked burnt and said she told the [NAME] that the sugar cookies were good to use. Interview on 11/02/22 at 9:44 am, the Dietary Director stated the dietary staff did a good job surface cleaning daily and deep cleaning weekly the kitchen with the use of a checklist. She stated all staff were responsible for cleaning their areas and the dietary staff could do better with labeling and storing food, but they only had two staff per shift. She stated if staff was already rushed, the dietary staff could be quick with putting the food up. She stated all dietary staff were responsible for storage/labeling food and drinks and said she was responsible for double checking behind them to ensure it was done. She stated she had two cooks, one prn cook and three aides and needed more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff. She stated she needed one double weekend cook and one dietary aide. She stated the dietary staff checked the dates, after the food deliveries and used the first in first out system with putting the new food items/drinks in the back and older food to the front and according to delivery dates. She stated not being sure why on Monday 10/31/22, there was a dirty metal serving cart inside of the dry storage room and added the dietary staff should have cleaned it before putting it into dry storage area. She stated dietary aide G was supposed to clean the dish rack dolly last night before she left and did not clean it before she left at 8:00 pm. She stated she was not sure when the shelf liner and prep knives were replaced. She stated when the kitchen was not cleaned properly, and food was not labeled correctly, it could lead to the residents getting sick with food poisoning and E. coli (bacteria toxin causing diarrhea, respiratory or pneumonia infections). Interview on 11/02/22 at 9:59 am, [NAME] D stated they did a good job labeling and storing food and drinks and most times all items were labeled. She stated food was good for up to 3 -7 days after the open date, and it depended on the type of food and the expiration date on it. She stated all dietary staff and dietary director cleaned the kitchen and stated they did a good job cleaning the kitchen. She said they used a cleaning checklist with the tasks of what to clean and once it was completed, she signed her initials. She stated the kitchen was cleaned three times per day after each meal service and in between as needed and added it was hard keeping the floor clean because they had to walk over it to continue with meal prepping meals. She stated the Dietary Director and all dietary staff checked behind each other to ensure they cleaned the kitchen right and threw out old and expired food. She stated she was not really sure when the knives and dish racks were replaced. Interview on 11/02/22 at 10:17 am, the Administrator stated they did a good job cleaning the kitchen. She stated all of the dietary staff were responsible for cleaning the kitchen and the Dietary manager oversaw it to ensure it was done. She stated she followed up with the dietary director with getting a power washer to clean the floor and added the kitchen floor was so old and some of the tiles were chipped. She stated she had not gone to the kitchen last Monday 10/31/22 but two weeks ago she checked the freezer and fridge for labeling and had an Inservice about it. She stated if chicken was in the fridge, it should have an open date on it and added the person storing the food was responsible for labeling and storing the food and ultimately the dietary director was responsible for ensuring it was done. She stated they had not ordered knives or dish racks lately because they had not been requested. She stated there were just some things that was clean but may not appeared to be clean and said she was not sure if the shelf liner for the pans was clean but the last time, she saw it was dirty and replaced was May 2022. She stated her expectation for food storage labeling and cleaning the kitchen was for it to be done properly and if they were not done right, it could cause residents to get sick with E.coli and food poisoning. Interview on 11/02/22 at 11:48 am, [NAME] E stated the dietary staff cleaned daily but needed to do a better job cleaning by doing more deep cleanings, which were done monthly. He stated they were good about labeling the food but staff at times were busy doing something else and rushed with food labeling. He stated seeing food that had been opened and not labeled and spoke to the dietary staff to slow down and label the food properly. He stated food was to be discarded after three days from the date the package was originally opened. He stated they have had the dish racks for 3 or 4 years that needed to be replaced because of some wear and tear and dirt on them and the white handle knives were about two or three years old. He stated the dietary staff used a daily checklist guide to confirm the microwave, steam table, fridge, floors and dish machine was cleaned. He stated once food was delivered, the dietary staff needed to put opened date and use by date labels on the food and milk products. He stated meat like chicken or beef needed a 3-day label and use by date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and the timeframe for labeling the food was same day as soon as they were taken out of the box. He stated the dietary staff swept and mopped the kitchen floors daily and the floor tech scrubbed, mopped and power washed and steamed the floors monthly. He stated if the kitchen was not cleaned right, and food not stored properly the residents could get food borne illnesses due to cross contamination. Record review of the facility's Food Storage Policy revised 2017 revealed, Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices .1. Food services, or other designated staff, will maintain clean food storage areas at all times .7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date. Such foods will be rotated using a first in - first out system .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) Record review of the facility's Sanitization Policy revised October 2008 revealed, Policy Statement: The food service area shall be maintained in a clean and sanitary manner .1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning Record review on 11/02/22 of the Dietary staff schedule sheet undated revealed five staff who worked Monday - Friday from 6:00 am - 8:30 pm and one dietary staff worked Saturday and Sunday from 6:00 am to 8:30 pm. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #26, Resident #15, and Resident #20) of 8 residents reviewed for infection control. Residents Affected - Some 1The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #26 and #15. 2The facility failed to ensure CNA B performed hand hygiene between glove changes while providing incontinent care to Resident #20 These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1Record review of Resident #26's Quarterly MDS assessment, dated 09/28/22, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, muscle weakness, schizophrenia and cognitive communication deficit. She had a BIMS of 15 indicating she was cognitively intact. Record review of Resident #26's physician orders dated 11/01/22 reflected, metoprolol tartrate tablet; 25 mg, give 1 tablet by mouth in the morning. Give with 50 mg tab to equal 75 mg; for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60 and heart rate less than 60. Review of Resident #15's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include airflow blockage, elevated blood pressure, and diabetes mellitus. She had a BIMS of 15 indicating she was cognitively intact. Record review of Resident #15's physician orders dated 11/01/22 reflected, lisinopril tablet; 10 mg, give 1 tablet by mouth, one time a day for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 100 or when the heart rate is less than 60. Observation on 11/01/22 at 7:30 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #26. LVN A did not sanitize the blood pressure cuff before or after using it on Resident #26. Observation on 11/01/22 at 7:50 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #15. LVN A did not sanitize the blood pressure cuff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 before or after using it on Resident #15. Level of Harm - Minimal harm or potential for actual harm Interview on 11/01/22 at 12:10 PM, LVN A stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time because she was nervous. Residents Affected - Some 2Review of Resident #20's quarterly MDS assessment, dated 09/23/2022, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: diabetes, chronic obstructive pulmonary disease (airflow blockage and breathing related problems), and depression. Review of the cognitive patterns reflected a BIMS of 07, which meant Resident #20's cognition was severely impaired. The bladder and bowel section reflected Resident#20 was always incontinent for the bowel and bladder. Observation on 11/01/22 at 8:10 AM revealed CNA B doing incontinence care for Resident #20. CNA B washed her hands using soap and water, and donned clean gloves. CNA B unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe and discarded. She then wiped the folds of skin at left and right groin area using a new wipe. CNA B turned the resident onto the right side. She cleaned the buttocks area with a disposable wipe. CNA B applied the skin barrier cream to Resident #20's buttocks. CNA B then removed the soiled brief and discarded into a trash bag. CNA B discarded the gloves and donned clean gloves without performing hand hygiene (washing or sanitizing) in between glove change. CNA B put a clean brief on Resident #20. CNA B discarded gloves and washed her hands. In an interview on 11/01/22 at 8:30 AM, CNA B stated she was supposed to perform hand hygiene in the beginning and at the end of the incontinent care procedure, and between change of gloves. She said she did not do it this time because she forgot. She stated the risk would be the spread of infection. Interview on 11/02/22 at 12:30 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She stated the expectation was the staff to perform hand hygiene before and after any care, and any time after removing dirty gloves. She stated if the staff's hands were visibly soiled, they were to clean with soap and water. Otherwise, they can use hand sanitizer. The DON stated the risk could be cross contamination. She said she was responsible for training staff on infection control. Review of facility's Infection Control Equipment and Supplies Policies and Procedures, undated, reflected did not address the concern (sanitizing blood pressure cuff between use). Review of the facility's policy titled Infection Control Gloves Policy and Procedure undated revealed, . 8. Handwashing is necessary when gloves are removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 11 of 11